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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
MAILING ADDRESS
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USE PERMIT
ZONE NUMBER 2,00.102
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SEPARATE PERMISSION.
STATE SURCHARGE
PERMIT APPLICATION: 180 DAYS
PERMIT LIMIT: I YEAR . PROVIDED WORK IS STARTED WITHIN 180 DAYS
ENG. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFO MATION
'APPLiCANT. ON BEHALF OF HIS OR HER SPOUSE. HEIRS. ASSIGNS AND SUCCESORS
IN INTEREST. AGREES To DEFEND AND HOLD HARMLESS THE CITY OF
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TOTAL AMOUNT DUE
INFORMATION
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BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
GRADiNGIFILL
DOMAIN (CURBS, SIDEWALKS, DRIVE YS, MAR DEES, ETC.) WILL REQUIRE
SEPARATEWBAMISSION.
STATE SURCHARGE
1.
PE M;TAPPLICAlA N: 180 DAYS
PERMIT LIMIT. I YEA. PROVIDED WORK 1. SITA TED WITHIN i8D DAYS
EKtG REVIEW FEES
SEE EIA _K OF OR MORE INFORMATION
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-APPLICANT. ON BEHALF OF HIS OR HER SPOLJSE� HEIRS. ASSIGNS AND SUC ESORS
ON .. ALF .
E INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY 0;
IN INTEREST, AGAM STO
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ANDSCAPING
2 EDMONDS, WASHINGTON, ITS OFFICIALS. EPAPLOYEES� AND AGENTS FR A YAND
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INSPECTION FEE
ALL CLAIMSFORDA AGESOFWHATEVER NATURE, ARISING DIRECTLYOR01'NDIRECTLY
A M S
RECEIPT
M THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
RO. THE ISSUANCE OF
P FRO
DEEMED TO MODIFY. WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
. To 0 IPy W ",
PLAN CHECK DEPOSIT
0 0 U MIT I Y W Y T E ORDINANCE PROVISION."
OX NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE AN
T07AL AMOUNT
El AT
I HERE Y ACKNOWLEDGE THAT: H E READ THIS APPLICATION: THAT THE INFORMATION
APPLICATION APPROVAL
GIVEN IS CORRECT, AND THAT AM THE OWNER, OR THE DULY AUTHORIZED AGENT 01
Th—PPI-1-11� I P'll 'It" 1', by III.
THE OWNER, I AGREE TO COMPLY WITH CITY AND S A E LAWS REGULATING CONSTRUC-
CALL
tyiI
d FI., d—,I
TION AND IN DOING THE WORK AUTHO.IZ D THEREBY. NO PERSON WILL BE EMPLOYED
OF WASHINGTON RELATING To
FOR INSPECTION
ipt i, k.owlIdgld in spaca provided+
IN VIOLATION OF THE LABOR CODE OF TEHE STATE
WORKMEN S COMPENSATION INSURANCE AND PCW 18.27
STG�ATURE DATE
0 11 SIGNED
(425)
�FICIALS
NER OR
MAE (OW Y
(:ZA
771-02?0
i RELEASED By ATE
ATTE14flON
EXT 333
IT IS UNLAWFUL.TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771 -0221
HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL FILE - YELLOW - INSPECTOR
A FINAL NSPECTION
CATE OFIOCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX PINK OWNER - GOL -ASSESSOR